Authorization For Third-Party Retrieval of Medical Records
ChartRequest is engaged in the business of obtaining copies of medical records. As the Client, and upon acceptance of these terms, Client has authorized in writing by Client's clients/customers to obtain the medical records for Client's clients/customers. Client has engaged the services of ChartRequest for the purpose of obtaining copies of medical records for Client's clients/customers. ChartRequest has been authorized by Client, who has been authorized by Client's clients/customers, to obtain copies of medical records from medical service providers. The purpose of this Authorization is to provide medical service providers with written proof of the authorization of ChartX by Client to obtain medical records from medical service providers.
Client hereby authorizes ChartRequest for the sole and limited purpose of requesting and scanning/retrieving medical records on behalf of Client for Client's clients/customers. Client hereby directs ChartRequest to request medical records from medical service providers for the purposes of scanning, digitizing, and transmitting to Client all medical records produced. A copy of Client's client/customer signed, written authorization shall be submitted to ChartRequest electronically or by mail or facsimile prior to ChartRequest's retrieval of any record for such client/customer. This Authorization is the "Authorization Agreement" referred to in that certain Agreement for Retrieval of Records between Client and ChartRequest, all of the terms and conditions of which are hereby incorporated by this reference.
BY USING THIS SITE AND SELECTING THIS CHECKBOX, I ACCEPT AND AGREE TO BE BOUND BY BOTH THIS AUTHORIZATION AND ALL OF THE FOREGOING TERMS, CONDITIONS AND PROVISIONS.I HEREBY CONFIRM THAT THE FOREGOING INFORMATION IS TRUE, CORRECT, ACCURATE AND COMPLETE IN ALL MATERIAL RESPECTS. I FURTHER REPRESENT AND WARRANT THAT I AM A DULY AUTHORIZED AGENT, EMPLOYEE OR REPRESENTATIVE OF FIRM OR ENTITY IDENTIFIED ABOVE AS EMPLOYER, AND THAT ACCEPTANCE OF THE TERMS, CONDITIONS AND PROVISIONS OF THE AGREEMENT AND THE AUTHORIZATION ARE AND SHALL BE BINDING UPON THE EMPLOYER.
Questions? Concerns? Suggestions? Please contact us at email@example.com or via U.S. mail at ChartRequest, ChartRequest
575 Pharr Road STE 52617 Atlanta, GA 30355 to report any violations of this Agreement or to pose any questions regarding this Agreement or the Platform.
These Terms of Service were last modified on the 25th of April, 2015.